Autonomy support encourages use of more-affected arm post-stroke

 I don't understand autonomy support at all, so I see no way to describe it to my doctors and therapists for use in recovery. So useless.

Autonomy support encourages use of more-affected arm post-stroke

• Sujin Kim,
• Yumi Shin,
• Yeonwoo Jeong,
• Seungyoung Na &
• Cheol E. Han 

Journal of NeuroEngineering and Rehabilitation volume 20, Article number: 116 (2023) Cite this article

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Abstract

Background

Autonomy support, which involves providing individuals the ability to control their own behavior, is associated with improved motor control and learning in various populations in clinical and non-clinical settings. This study aimed to investigate whether autonomy support combined with an information technology (IT) device facilitated success in using the more-affected arm during training in individuals with stroke. Consequently, we examined whether increased success influenced the use of the more-affected arm in mild to moderate subacute to chronic stroke survivors.

Methods

Twenty-six participants with stroke were assigned to the autonomy support or control groups. Over a 5-week period, training and test sessions were conducted using the Individualized Motivation Enhancement System (IMES), a device developed specifically for this study. In the autonomy support group, participants were able to adjust the task difficulty parameter, which controlled the time limit for reaching targets. The control group did not receive this option. The evaluation of the more-affected arm's use, performance, and impairment was conducted through clinical tests and the IMES. These data were then analyzed using mixed-effect models.

Results

In the IMES test, both groups showed a significant improvement in performance (p < 0.0001) after the training period, without any significant intergroup differences (p > 0.05). However only the autonomy support group demonstrated a significant increase in the use of the more-affected arm following the training (p < 0.001). Additionally, during the training period, the autonomy support group showed a significant increase in successful experiences with using the more-affected arm (p < 0.0001), while the control group did not exhibit the same level of improvement (p > 0.05). Also, in the autonomy support group, the increase in the use of the more-affected arm was associated with the increase in the successful experience significantly (p = 0.007).

Conclusions

Combining autonomy support with an IT device is a practical approach for enhancing performance and promoting the use of the more-affected upper extremity post-stroke. Autonomy support facilitates the successful use of the more-affected arm, thereby increasing awareness of the training goal of maximizing its use.

Trial registration

The study was registered retrospectively with the Clinical Research Information Service (KCT0008117; January 13, 2023; https://cris.nih.go.kr/cris/search/detailSearch.do/23875).

Background

Functional improvements obtained through rehabilitation often do not increase the use of the more-affected arm in real-world situations [1, 2]. Multiple clinical trials on constraint-induced movement therapy [3, 4], task-oriented movement therapy [5, 6], and high-dose training [7, 8] have aimed to overcome this discrepancy between function and use of the upper extremity (UE) by increasing the use of the more-affected arm. In the same context, the factors influencing the use of the more-affected arm have been explored, and attempts have been made to incorporate them into treatment approaches to improve their therapeutic effects. These factors include cost (e.g., biomechanical effort), reward (e.g., task success), side of stroke, and hand preference before stroke, which affect the decision of arm choice [9,10,11]. Recently, socio-cognitive behavioral factors such as autonomy support, self-efficacy, and attention/arousal have been gaining attention for their potential impact on the spontaneous use and recovery of the UE post-stroke [12,13,14,15,16].

Autonomy support facilitates the basic psychological need of individuals to control their own behaviors [17, 18]. Known to facilitate motor control and learning in clinical and non-clinical populations [19, 20], it is now among the principal concepts of patient-centered intervention programs. For instance, such intervention programs encourage patients to actively participate in planning and selecting task order and difficulty [6]. Autonomy support has also been found to be associated with self-efficacy. [18]. Self-efficacy, one’s belief in their capacity to complete a certain task [21], is an important factor affecting use of the more-affected arm [12, 22]. While such socio-cognitive behavioral factors have increasingly emerged in stroke rehabilitation, it remains necessary to investigate their effects on the dynamics of recovery.

Here we examined the effect of autonomy support on the use of the more-affected arm post-stroke. Since previous studies indicated that autonomy support led to better performance [18, 19, 23], we hypothesized that autonomy support would boost task success with the more-affected arm, and consequently, the accumulated success would facilitate the use of that arm. This aligns with the context of the previous research that successful performance with the more-affected arm, especially combined with high repetitions, can reinforce its spontaneous use [4, 24,25,26]. Thus, this study included simple high-dose repetitive reaching movements with autonomy support wherein the patients actively participated in selecting task difficulty. This training approach might promise patients with stroke a greater chance of successful outcomes. Concurrently, to maximize the learning effect on spontaneous use of the more-affected arm, we applied “choice training,” which allowed participants to choose which arm to use.

A distinctive feature of our study was the utilization of a novel information technology (IT) device, which allowed patients to adjust their task difficulty, thereby facilitating autonomy support. A previous study on UE training via IT systems was successful in attaining increased use of the left non-dominant arm in healthy participants [27], while visual augmentation providing a more successful experience improved the use of the more-affected arm in stroke survivors [28]. However, these systems automatically changed the task difficulty based on the performance, so they did not monitor dynamic changes in patients’ behaviors during training sessions, such as the task difficulty selection and changes in motivation variables. Our novel system overcomes these limitations by allowing the active involvement of participants in changing task difficulty or training schedules during training.

This study aimed to investigate the effects of autonomy support on the ability of the participants with stroke successfully use their more-affected arm both during and after training. In addition, we examined the dynamic changes in self-efficacy and association with the use of the more-affected arm.

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